Healthcare Services Contract
Welcome to Dr. Winton’s office, integrative health care for the body and mind. This document contains important information about professional services and business practices. Please read it carefully and ask any questions you have about the information.
Naturopathic Medicine requires an active effort on your part, and in order to be successful, you will need to be willing to make certain lifestyle, behavioral, and/or dietary changes. Naturopathic Medicine takes a comprehensive approach to wellness, focusing on the body, mind, and spirit. Naturopathic medicine can be very effective in treating both acute and chronic illness and is preventative in nature. Your initial visit is an information gathering session that allows the physician to better evaluate your health care needs and appropriate therapeutic treatments. If you have any questions or concerns, please let the doctor know at your initial visit, so they may be addressed immediately.
Information regarding your treatment will not be released without your written permission except in the following circumstances, which are mandated by law.
1.) If you threaten grave bodily harm to another person or yourself, I am required to inform the intended victim, and appropriate law enforcement agency, family members or others who can provide protection, I am under legal obligation to warn and protect.
2.) I must report actual or suspected abuse to children, the elderly, or the disabled.
3.) I must comply when a report is ordered by a Court of Law
Please be aware that insurance health care plans may involve direct clinical management by the insurance company and may have some impact on confidentiality. Please refer to HIPPA notice of privacy practices for more information
regarding how your personal health information is utilized.
If I am given the opportunity to purchase any substance or device from Dr. Winton, I understand that this is a natural substance or device, which may be filled by another doctor of naturopathic medicine or by a pharmacy of my choice. Furthermore, I understand that I am under no obligation to purchase any natural substance or device from Dr. Winton.
I understand that if I have an urgent medical condition, and I am unable to reach Dr. Winton directly, at 480-704-1050, it is my responsibility to seek appropriate medical care. I further understand that if there is a medical emergency or serious medical concern, I am to call 911 immediately
Consent to Treatment
I authorize Dr. Winton to administer treatment and perform such general procedures, as he deems
therapeutically necessary in the diagnosis and treatment of my condition. I understand that no guarantee or assurance has been made as to the results that may be obtained from such treatment. I understand that Dr. Winton intends to provide top quality care. However, if I am unhappy with services I received, I intend to immediately tell Dr. Winton and/or his staff, so that my concerns/complaints can be addressed immediately. If I am pleased with my care, I have the option of referring my friends and family.
I have read this form and agree to all its contents with my signature below.
In the state of Arizona Naturopathic Medical Doctors are not covered by Insurance at the time of service. We provide our patients with billing sheets which have diagnosis codes and procedure codes for the patient to submit directly to their insurance company for reimbursement. It is up to your insurance company to decide whether to reimburse you for your visit and the amount they will cover. We do however accept health savings and flex spending accounts to cover all your treatment services and supplement purchases at our office. We provide you with a lab order to have
your blood drawn at an outside lab (Sonora Quest or LabCorp) for insurance to cover.
I understand that this is a patient directed therapy and I am directing Dr. J Todd Winton to perform the procedure(s) necessary to restore my health and that in doing so I, and any and all parties that may represent me or my estate, hold harmless the staff and all other controlling or involved entities or manufacturers. In the event of a dispute, I and/or my above representative parties agree to binding arbitration that follows the rules of the American Arbitration Association.
I understand that if I am unable to keep my appointment that I will give a 24 hour notice or I will be subject to either a penalty of $35 or the cost of that service, whichever is less.
Any refunds on packages will be reimbursed at the standard rate.